Carnival Cruise Lines, like most other ocean lines serving North Americans, has a full-bodied onboard medical clinic, staffed with knowledgeable personnel and featuring up-to-date equipment.*

By Marilyn Green and Susan J. Young

When you’re enjoying a relaxing and much needed cruise vacation, the last thing you want is to end up in the ship's medical clinic.

To help ensure a carefree vacation, buytravel insurance that covers medical emergencies overseas. Also, educate yourself now about how to avoid stomach flu, sunstroke, accidents and falls onboard (not that uncommon).

Following is a look at the medical facilities onboard cruise ships, the quality of care, what you can expect if you need to visit the infirmary, how to handle pre-existing conditions, what the “dreaded” norovirus is and how you can avoid it, and why travel insurance is important.

Cruise Line Medical Resources

Oceangoing cruise ships have registered nurses and doctors onboard. Some river cruise vessels sailing within the U.S. South have medical personnel onboard; others do not, due to the vessels' close proximity to land-based resources. Check with your line.

The number of medical personnel on any ship is usually based on the number of passengers and the passenger mix. For instance, Carnival Cruise Lines (its infirmary on one ship is shown above*) carries one doctor and three nurses on its Fantasy- and Spirit-class ships. In contrast, Carnival carries two doctors and four nurses on the larger Destiny and Conquest class vessels.

Ships carrying fewer than 600 passengers generally carry one doctor and one nurse. On so-called World Cruises that sail for three to four months, you might even find dental staff onboard. Dentists, though, are generally not present on shorter voyages.

Obviously, fluency in English is a key issue in onboard medicine. The good news is that most lines hire English-speaking medical staff from the U.S., Canada, the U.K., Australia, New Zealand and South Africa, with some multi-lingual staff members coming from Europe.

Among the check-list of things passengers should know is that the medical officer’s authority is complete. If you are told to disembark, you must.

Also, the Florida Supreme Court recently upheld the ruling that cruise operators are not responsible for malpractice by shipboard medical personnel, who are considered independent contractors. That said, onboard medicine has changed drastically since the early days of cruising, when doctors onboard ships were nowhere near the peak of their professions.

Assuring Quality Medicine at Sea

Today, the cruise lines have found ways to bring very capable medical personnel onto their ships. Princess, for example, hires only Marine Medicine specialists who work at sea full time.

Windstar Cruises taps emergency room personnel from Seattle hospitals to rotate in and out of its shipboard infirmaries. This gives the hospital staff some relief from a difficult, day-to-day practice on land. And cruise ships guests are, in turn, treated by excellent emergency room professionals, clearly skilled at handling all types of urgent care cases.

During the past decade, several prestigious medical schools have begun offering specialized courses in cruise ship medicine as an offshoot of their emergency medicine programs.

Medical guidelines developed by the International Council of Cruise Lines (now part of Cruise Lines International Association) and the American College of Physicians have set new cruise industry standards. Now there are very specific requirements in experience for doctors and nurses on ships.

All ships built after early 1997 also must have X-ray equipment onboard. Specific medications are required, as is a variety of medical equipment.

Many shipboard clinics boast defibrillators, EKG machines, external pacemakers and ventilators, to name a few pieces of vital equipment. The goal is to meet the needs of today’s passengers, many of whom won’t allow health issues to interfere with their desire to cruise.

Williams noted that Carnival and other lines do a tremendous amount of training in cardiac care. He said the industry is in the midst of a five-year study that appears to indicate that a person is slightly more likely to survive a cardiac attack on a ship than on land, due to the speed of shipboard response.

Telemedicine has given ships’ doctors the ability to consult with experts on land even while miles out at sea. Many cruise lines have relationships with land-based facilities, including the University of Texas Medical Branch at Galveston, George Washington University Hospital, Miami’s Jackson Memorial Hospital and The Cleveland Clinic.

Some newer ships – those built in the past seven years – have the capability to electronically transmit digital X-rays and other test results to specialists ashore. So your onboard doctor likely has new resources -- and a pool of landside specialists -- available for consultation.

Onboard Clinic Hours and Costs

Cruise ships typically have specified clinic hours – usually a short window once or twice each day when you may be seen by either a nurse or a doctor. The hours are announced in the daily newsletter left in your cabin.

At right, a doctor and nurse review a patient's test results onboard a high-tech computer within one of the Carnival ship infirmaries.*

If a serious illness or condition develops, though, the ships also are set up for a 24-7 emergency response. Usually, you call the purser’s office or the bridge about an emergency. Medical personnel will be dispatched.

Costs for normal onboard medical center visits usually run between $40 and $100. There are additional charges for tests, medications and after-hour services.

Seasickness and gastrointestinal problems, though, may be treated without a charge. Most cruise ship infirmaries, and even the purser’s desks at times, carry seasickness pills.

Pre-Existing Conditions and Medication

Let the cruise line know ahead of time if you have a pre-existing medical condition that might require treatment onboard. For example, this might include diabetes, high blood pressure, a heart condition or other major illness. Or perhaps you simply need stitches removed at a certain time or a wound re-wrapped.

Those who would like to continue physical therapy while onboard should also alert the line. Most cruise lines have a full complement of fitness-trained personnel. Depending on the therapy required, they may be able to assist. It's not guaranteed certainly, but it's worth asking about.

If you have just had surgery or are in a wheelchair and need assistance in boarding and disembarking (see the Carnival Cruise Lines photo at left*) just let the line know in advance. Even those who are fully confident and comfortable in wheeling their own chair (and who don't need any assistance whatsoever onboard) might consider assistance for the "on" and "off" journeys if the chair is not motorized.

We've learned first-hand that the extensive ramps on and off the biggest ships are often-multi story and at a fairly steep grade. Elevators are available on the ship and within the cruise terminal itself. But wheelchairs still have to navigate the ramps between the terminal and vessel.

Editor's Note: On a recent Royal Caribbean trip, I definitely needed assistance for my mother in pushing her transport chair up the various ramps, which snaked up through multiple levels in Miami. She didn't need the chair for every activity onboard, but could not walk the distance nor the grade to embark or disembark. The cruise line was extremely helpful in providing a crew member or passenger assist representative to help in boarding and disembarkation.

If you use prescription medicine, bring plenty -- enough for an extra week or two, just to be safe. Don't pack medicines in your checked baggage.

And don't assume your medicines will be available from the onboard pharmacy. If you do run out of a medicine and the onboard pharmacy doesn't have it, it's likely not just a matter of having your pharmacist at home call the foreign pharmacy.

You may need to visit a doctor in that country for a prescription to be filled. That's just another reason to err on the conservative side when carrying medications. Take more than you need.

Editor’s Note: Bring copies of medical records. On a recent cruise I took documentation of my mother’s previous heart attack, pacemaker surgery and even EKG test results. She developed an unexpected infection onboard. In our visit with the Princess Cruises’ doctor, the records proved immensely helpful in assisting him to deal with her medical issues. She received good treatment and was able to enjoy the rest of her cruise.

Also, let the cruise line know if you have special dietary needs. For example, tell them if you have need for low-salt or gluten-free dishes.

Definitely, let the cruise line know if you require oxygen onboard. Policies may vary by line as to whether you may bring your own, or whether the oxygen will be provided by the line for a fee.

These issues should be addressed many weeks, if not months, prior to departure.

Staying Safe and Healthy on Vacation

Many injuries onboard cruise ships are caused by guests of all ages who don’t look down or take hand rails. Tripping and subsequently falling is not uncommon – and this doesn't just happen to elderly folks.

Editor’s Note: On a recent cruise my neighbor took, the ship was only a couple miles out of Port Canaveral when a young boy (not a toddler) tripped and fell and broke his arm. The ship turned around, took the boy and his parents back to shore where he was offloaded, met by ambulance and transported to a local hospital for care. Bottom line: the cruise departed without this family and their vacation was over.

Some older ships may have a “lip” or bulkhead "rise" of several inches at points along the corridor. You may need to step up and over.

But watch your step even on newer ships. Despite the latest stabilizer equipment, it's relatively common to have a bit of "motion" at some point during a cruise. If you're not steady on your feet, use the hand rails provided in corridors and along staircases.

Bathrooms within cabins are often raised -- requiring a step up to enter. Care is needed as it’s not the normal configuration we are used to at home. Plus, space in cabins is often tight. So it’s quite easy in the dark to run into furniture, trip over something or stumble going into the bathroom.

If you get up to use the bathroom at night, bring a nightlight. Or, simply leave the light on in the bathroom and pull the door shut. The light filtering out under the door is a good nightlight.

Everyone wants to have fun on their cruise. But too much sun may land you in the infirmary and also cause a lot of skin pain for the rest of your cruise. Use sunscreen and don’t stay out in the intense Caribbean sun for as long as you might at home. You’ll pay for it. And you might even end up with sunstroke.

Editor’s Note: On a Disney Cruise several years ago, I was enchanted with Castaway Cay, the line’s private island. I went to the adult beach, an enclave of pampering and relaxation. There were no kids and it was not crowded. It seemed like heaven. I didn’t seem to be getting much of a tan so didn’t put on much sunscreen. An hour after returning to the ship, the “lobster burn” suddenly appeared. During the night, I had heart palpitations and almost went into shock. I won’t repeat that mistake and neither should you! Just because the private island experience seems like heaven, don’t forget to keep lathering on the sunscreen; and use SPF30 or higher. Remember, in the Caribbean (closer to the Equator) the effect of the sun’s rays is stronger. You’ll burn in a much shorter time.

Some cruisers also end up in the infirmary for over-indulging. If you’re not used to chowing down and stuffing yourself for breakfast, lunch and dinner at home, not to mention snacks, pizza, room service and late-night options, don’t do it at sea. Yes, enjoy yourself while dining but aim for moderation.

Similarly, if you don’t normally drink five glasses of wine at dinner or have three pina coladas at lunchtime, don’t do it on a ship. Your stomach may simply rebel.

Also be careful with foods that could lead to allergic reactions. Many cruise lines usually label sugar-free and fat-free items in both the buffet and dining rooms. If you’re not sure if seafood is in a dish and you’re allergic to seafood, either ask the staff or just forego the dish. Ask questions before chowing down.

Protecting Passengers: The Vessel Sanitation Program

Worried about getting sick at sea because of contaminated water or food? It's highly unlikely. In fact, rarely does one ever hear of a salmonella outbreak onboard a ship. Those situations have been virtually eliminated -- thanks to the U.S. Centers for Disease Control's Vessel Sanitation Program (VSP).

As a result of this program, your cruise ship galley may be cleaner and less of a health threat than your favorite restaurant’s kitchen at home.

Given that cruise ships are floating "cocoons" of sorts, the CDC developed the VSP program to ensure your cruise ship is tip top for sanitation. Twice a year, VSP staff inspect all cruise ships with a foreign itinerary if those ships call on U.S. ports and if they carry 13 or more passengers.

Inspections are unannounced. The cruise lines never know when the VSP inspectors will show up. The goal is to assure vessels are maintaining adequate levels of sanitation and to provide guidance to vessel staff for improvements.

For example, the VSP inspectors look at water supply — storage, distribution, protection, and disinfection; spas and pools --filtration and disinfection; food protection -- storage, preparation, and service; and employee hygiene practices. In addition, inspectors evaluate the physical condition of the ship, such as general cleanliness and the absence of insects or rodents.

Inspections are scored on a point system of 100. At times, ships even rate a perfect score on the stringent requirements.

For example, The Island Princess (one of its galleys for preparing guest food is shown at right) was awarded a 100 score on its December 2006 inspection.*

Ships that score an 86 or higher are considered to have a satisfactory sanitation level.

Ships that score an 85 or lower have an unsatisfactory sanitation level and will be reinspected, usually within 30-45 days to determine if conditions have improved.

The government says that, in general, the lower the score, the lower the level of sanitation. But it also says a low score does not necessarily imply an imminent risk for gastrointestinal illness. Since the VSP began, disease outbreaks on ships have declined although the number of ships sailing and passengers carried has increased significantly.

And if a ship fails an inspection – and even the best ones do now and then – the deficiencies are caught and fixed immediately in most cases.

You may review these inspection scores. Just go to the VSP Web site www.cdc.gov/nceh/vsp/default.htm. Click on the “Green Sheet” to pull up the list of the most recent inspection scores by date and ship. Generally, most ships that regularly serve North Americans score well above passing.

Avoiding the Stomach Flu

When you feel ill, though, head for the infirmary. Quick action may ultimately get you on the road to recover much quicker.

That brings us to the Norwalk virus (also called norovirus). The reality is that this highly publicized virus -- improperly called the "cruise ship virus" -- is actually just as prevalent on land. It’s basically “stomach flu,” and is nearly as frequent within the general worldwide population as the common cold.

It’s not caused by contaminated food or water. It’s most often picked up by touching surfaces that an infected person has touched.

If you get it after flying on an airplane or staying at a hotel, you just chalk it up to the flu. No hotels, convention centers, airlines or other travel venues are required to track or report outbreaks. But the U.S. Centers for Disease Control require cruise lines to report the occurrence of this virus is even only 2 percent of those onboard contract it.

Thus, when it strikes, headlines emerge. That's really a bad rap for the cruise industry. Anecdotally, in the United Kingdom, norovirus is so prevalent on land, that travel agents have signs in their windows, telling people to cruise and “escape” the Norwalk virus!

This virus is seldom dangerous (depending on your health or age). But it is extremely unpleasant and irritating when it occurs on vacation.

To put it bluntly, victims are hit with immediate and frequent bouts of vomiting and diarrhea. Usually it vanishes as quickly as it came – after just a day or so.

Testing for the stomach flu on a ship is now usually quite quick. If you have it, the cruise industry’s response – as recommended by the CDC -- is to treat you and then confine you to your cabin for several days (meaning you’ll miss any shore trips or onboard activities those days but most folks are too sick to participate anyway). This is crucial to prevent further spread of the highly contagious illness.

Even the noncontagious person in your cabin – your spouse or friend – may also be confined with you. The cruise staff will have meals delivered to your cabin.

How can you avoid this stomach flu and cabin confinement? Experts agree that the best preventive measure is prolonged hand washing with soap and hot water (sing two choruses of Happy Birthday to yourself and that’s how long you’ll need to wash).

Hand wipes or sanitizers offered on many cruise ships are not intended to replace hand washing but to supplement it. Use these as well. They’re often found at the entry to dining venues, the casino and at the gangway.

Remember, norovirus is often rampant on land, so use the sanitizers when returning from a shore trip; then immediately go wash your hands thoroughly. Many so called “sick ships” were not sick until passengers brought the virus onboard.

The cruise lines also have pioneered cleansing solutions for controlling the spread of norovirus. That’s why you see cruise line staff constantly wiping down banisters, elevator “touch” surfaces, and so on.

During a norovirus outbreak, to prevent more folks from becoming ill, the buffet line may be closed to “passengers spooning out their own food." Instead, crew will serve you the dishes wearing plastic gloves. This is all part of a full “protocol” of preventive measures the cruise lines follow when norovirus cases have been reported onboard. It's all designed to protect you!

Keep yourself healthy:

Wash your hands religiously onboard – every time when you return to your stateroom; when returning from any shore trip; after using handrails; elevator buttons; slot machines; Internet café keyboards; or other surfaces other cruisers have touched; after using the bathroom; and before any meal.

Use the hand sanitizer machines. Don’t say “oh I just washed my hands.” Just do it.

Keep your hands away from your eyes and mouth. If you touch a surface that has been touched by a person with the virus, then you brush your eye or wet your lips, presto, the virus has a way in…

If you see someone become ill (vomiting or diarrhea), the CDC says leave the area and immediately alert the ship's staff to assist. You could become ill if you ingest contaminated particles that travel through the air from a sick guest.

Protect your financial future. The number one recommendation the experts make is to buy travel insurance. Many people simply don’t realize that most U.S. health insurance coverage ends at this country’s shores.

Medicare, for example, is not accepted overseas nor are most private insurance policies. Check with your health care provider.

The best travel insurance policies include coverage for medical evacuation, emergency care and hospitalization as well as lost luggage and trip delays. Your travel agent can assist in securing this insurance. (Editor’s Note: An upcoming feature in this publication this summer will look in more detail at travel insurance options).

While medical care on cruise ships has advanced dramatically in the past few years, if you have a broken leg, a heart problem, or some other major medical situation, you’ll likely receive “emergency” care while at sea and then be taken off the ship at the next port of call for treatment at a hospital.

If a truly serious condition results while you’re still at sea, you might even be evacuated from the ship by helicopter. That could cost $25,000 or more. So, purchasing travel insurance with medical and evacuation coverage is a “must.”

That said, travel insurance is generally designed to reimburse you after you return home. Land-side medical facilities overseas may require cash up front. So, protect yourself with travel insurance, but also have some on-hand financial resources – traveler’s checks, credit cards and the ability to draw cash out of foreign ATMs – while you are traveling. Some foreign hospitals may take credit cards, but not all do

Editor’s Note: An elderly friend of mine recently had an unexpected fall in Florence, Italy while on a cruise line shore trip. She broke her wrist and was taken to a local hospital. In this case, the hospital felt this was a true emergency so they did not charge the woman. But this is often not the case. It’s always a good idea to have both travel insurance and some reserve funds – whether credit cards or traveler’s checks – for unexpected emergencies while on your cruise.

The Odds are Good

Chances are very good that your cruise will be hassle-free and you won’t need to visit the infirmary while on your cruise vacation -- any more than you'd need to visit a land-based clinic while on a vacation to Latin America or Europe.

You can increase those odds by washing your hands frequently, by not putting your hands to your eyes or mouth, by eating and drinking in moderation, by putting on sunscreen, and by using the ship's handrails and by taking care when getting up at night to use the bathroom.

But if you do end up in the infirmary, it’s nice to know that the quality of onboard medical care is greatly improved from just a decade ago.

“The cruise lines are carrying more and more people who have health issues and we are working hard to make each vacation a success for them,” Williams said. “The numbers [of guests who come and go without any health problems onboard] will only increase.”

Marilyn Green has freelanced for nearly 30 years in consumer and trade magazines including Travel & Leisure, Islands, British Heritage and others. From the Macleod clan, she is based in New York City. Despite spending much of her life in Edinburgh, the west coast of Scotland and Kentucky, she quips that she still can't play the bagpipes.

Susan J. Young is editor in chief for SouthernTravelNews.com™ and SouthernCruising.com™. She is the former Southeast Bureau Chief and Cruise Bureau Chief for Travel Agent Agent magazine and a former newspaper reporter. She is a member of the Society of American Travel Writers (SATW) and that organization's Editors' Council. Her articles have appeared in many national and regional publications. She has won several major awards for her aviation writing.

*Photos are owned, copyrighted and used with permission of Carnival Cruise Lines and Princess Cruises. All rights reserved. Please do not link to nor copy these photos. Thank you.